Is paramedic judgement useful in prehospital trauma triage?

Precise prehospital trauma triage criteria are critical for ensuring patients with severe injuries are transported to trauma centres. Most prehospital trauma triage criteria adopt a combination of physiological, anatomic and mechanism of injury components, but this approach still fails to identify a number of patients with severe injuries and often burdens trauma centres with patients suffering minor injuries. Paramedic judgement has been identified as an alternative method for the triage of trauma patients. This study critically reviewed the literature regarding the ability of paramedics to predict injury severity, and found there is no clear evidence supporting paramedic judgement as an accurate triage method. However, the studies were limited due to significant data losses, variable definitions of major trauma, differences across EMS and trauma care systems, variable paramedic experience levels and incomparable methods of data collection. The role of paramedic judgement in identifying patients with severe blunt anatomic injuries requires further investigation.     

Trauma team activation: simplified criteria safely reduces overtriage

BACKGROUND: Our current trauma triage system uses patient and scene variables within a 3-tiered trauma response system. Our purpose was to evaluate the accuracy of the current system and to identify the most reliable variables for trauma triage. METHODS: This was a retrospective review at a level II trauma center. Multivariate logistic regression was used to identify independent predictors of the need for any urgent emergency department procedure or operative intervention. The current triage system was analyzed and compared with a proposed simplified system. RESULTS: There were 1495 consecutive trauma admissions identified, the majority (88%) were blunt mechanism. Urgent emergency department interventions were required in 11%, and 4% required emergent surgery. Logistic regression demonstrated that prehospital Glasgow Coma Score <14 (odds ratio [OR] 9.7), hypotension (OR 3.3), altered respiratory effort (OR 4.6), and penetrating truncal injury (OR 10.8) independently predicted the need for urgent intervention (all P < .01). The current system undertriaged only 1% but overtriaged 51% of patients. A simplified triage system using these 4 variables significantly decreased overtriage and reliably identified patients with severe injury. CONCLUSIONS: A simplified triage system using only highly predictive variables can safely decrease the high rate of overtriage of trauma patients.     

A method for evaluating field triage criteria

The primary goal of triage is to identify the majority of field trauma victims at risk for life-threatening injuries. When triage criteria are made sufficiently sensitive to accomplish this goal, high rates of overtriage occur. Orange County's original physiologic criteria were associated with an overtriage rate of 18-40% depending on the definition of a major trauma victim. During the first year's experience with the original physiologic criteria, 21% of non-CNS motor vehicle trauma deaths occurred in nondesignated hospitals. When the criteria were made more sensitive by adding non-time dependent triage criteria such as anatomic and mechanism of injury criteria, deaths in nondesignated hospitals dropped to 4.4%, but the rate of overtriage doubled. Despite this apparent high rate of overtriage, only 5.5% of all paramedic transports were for patients judged to have met field triage criteria. Based on this experience, an approach is suggested for evaluating the balance between over- and undertriage that occurs for a given set of triage criteria. Once this balance has been defined, triage guidelines can be modified to meet regional triage objectives.     

The utility of physiological status, injury site, and injury mechanism in identifying patients with major trauma

It has been suggested that if triage criteria are to identify accurately patients with major trauma, not only physiologic status, but also anatomic site and injury mechanism must be assessed. This study examined the influence of physiologic, injury site, and injury mechanism criteria on the diagnosis of major trauma in 2,057 trauma patients. Because the Trauma Score was found to be a highly specific indicator of major trauma (98.7%), the strategy adopted for isolating the factors that minimize inappropriate triage was to determine which, alone or in combination, are the most effective in identifying patients with major trauma among those with high Trauma Scores (greater than 12). Based on this analysis, a set of triage guidelines was developed. The application of these guidelines to the study population indicated an undertriage rate of 4.1 to 6.3% and an overtriage rate of 16.8 to 21.3%, depending on the definition of major trauma.     

A prospective evaluation of field categorization of trauma patients

We prospectively evaluated the efficacy of comprehensive field triage in 8,891 trauma patients transported to trauma centers in Dade County, Florida, over a 1-year period ending in September 1986. There were 5,685 males (63.9%) and 3,206 females (36.1%) with a mean age of 32.4 +/- 18.4 years. The overall accuracy for identifying severe injury for the entire group was 30.2%. A Trauma Score less than or equal to 12 was the most accurate predictor of severe injury. Of 669 patients in this group, 617 (92.2%) sustained severe injury and 361 died (54.0%). High-speed (greater than 40 m.p.h.) motor vehicle accident was the most common reason for triage; however, of 2,277 in this group 201 patients (9.0%) had severe injury and four patients (0.2%) died. Only nine deaths (0.9%) occurred in 1,004 patients with penetrating trauma whose Trauma Scores were greater than 12. Of the 8,891 patients 4,791 (53.9%) had moderate to severe injury. The overtriage rate was therefore 46.1% using this field categorization system.     

Secondary overtriage: a consequence of an immature trauma system

BACKGROUND: Trauma systems are designed to bring the injured patient to definitive care in the shortest practical time. This depends on prehospital destination criteria (primary triage) and interfacility transfer guidelines (secondary triage). Although primary undertriage is associated with increased costs and worse outcomes for selected injuries, secondary overtriage can overwhelm system resources and delay definitive care. The purpose of this study was to determine the incidence of secondary overtriage in a region without a formal trauma system. STUDY DESIGN: Retrospective cohort study of trauma registry data at an American College of Surgeons Committee on Trauma-verified Level I trauma center and regional referral center. Secondary overtriage was defined as patients transferred from another hospital emergency department to our trauma receiving unit who had an injury severity score < 10, did not require an operation, and who were discharged to home within 48 hours of admission. RESULTS: Data on 9,064 patients were reviewed; 6,875 (76%) arrived directly from the scene and 2,189 (24%) were transferred. Although the transferred group was more severely injured, the majority (64%) had minor injuries and 824 (39%) met secondary overtriage criteria. The degree of secondary overtriage and injury pattern varied with respect to referring facility. Peak admission day and times for overtriage patients coincided with scene admissions trauma receiving unit closure events. Patient payor mix and facility cost and reimbursement profiles did not differ between scene and transfer overtriage patients. CONCLUSIONS: A substantial proportion of transferred trauma patients require only brief diagnostic or observational care. Excessive overtriage calls for development of a regional inclusive trauma system with established primary and secondary triage guidelines to improve access to care and trauma system efficiency.     

Impact of minimal injuries on a level I trauma center.

Overtriage (i.e.; transport of patients with minimal injuries to a trauma center) has been accepted as necessary to avoid missing clinically significant injuries. We reviewed our experience with 344 patients (ISS less than or equal to 4) who were admitted to a level I trauma center during a 2-year period. The trauma team was activated for 209 patients (TA), and emergency department referrals accounted for 135 (ED). One hundred seventy-three patients (TA = 64%, ED = 36%) met American College of Surgeons' Committee on Trauma (ACSCOT) field triage criteria (FTC). Mechanism of injury, especially ejection from a motor vehicle, was the most frequently utilized FTC indicator. We found no differences between the TA and ED groups relative to Trauma Score, Glasgow Coma Scale score, Injury Severity Score, length of stay, or ICU days. Mean total costs were higher for the TA group than for the ED group. The TA group had a higher nursing acuity level than the ED group. Compliance with FTC yields an inherent overtriage of minimally injured patients; however, noncompliance with FTC compounds the overtriage rate. Failure to comply with FTC is costly, labor intensive, and may represent misuse of the trauma system. We propose continual re-education of prehospital personnel, increased responsibility of all hospitals in the trauma center catchment area, and protocols for "downstaging" trauma resuscitation in minimally injured patients.     

The effect of medical direction on trauma triage

Effective field triage of trauma victims requires identification of patients at risk of dying and their rapid transport to hospitals capable of treating severe injuries. Identification of these patients at the accident scene can be difficult since prehospital personnel receive little training in structured triage decision making. The role of the physician in routine triage is disputed and his/her value has not been documented. This study explored the severity of injury of three groups of trauma patients triaged by different guidelines to a Level I urban trauma center. Results showed that with physician input in the triage process, patients chosen for helicopter transport to the trauma center had a significantly higher median level of injury severity than patients triaged to the trauma center without physician involvement. The results have implications for controlling overtriage of patients to trauma centers.     

Evaluation of injury mechanism as a criterion in trauma triage

Triage of potentially injured patients to the appropriate trauma hospital was carried out using mechanism of injury as a triage criterion rather than physiologic changes (trauma score). Injury mechanism includes field evidence of high energy transfer, such as falls of more than 15 feet, automobile accidents with structural intrusion, extrication difficulties, passenger ejection, or death at the scene. Evaluation of triage decisions for a 3 month period in 631 patients showed an overtriage rate of 14 to 43 percent. Using the trauma score alone would have missed significant injuries in at least 8 to 36 percent of these patients using the injury severity score or clinical criteria. Methods of evaluation of overtriage and undertriage are presented, but accepted standards for these must be addressed in each trauma system. Injury mechanism as a primary trauma triage criterion is an acceptable means of identification of potential injury for transport to a trauma facility.     

The hospital trauma team: a model for trauma management

A triage system was established as the initiating mechanism for a trauma team response to assist the assessment and early management of patients presenting to an accident and emergency department. A checklist of triage criteria was used. During a 6-month period, 342 patients (29.7% of trauma admissions) satisfied the triage criteria, which should have resulted in an average of 1.9 trauma team calls per day. Staff compliance with the triage tool was 75.4%. The overtriage rate for the checklist criteria was 52.7%. The triage tool identified patients with severe injuries who were not initially considered sufficiently injured to justify initiation of the trauma team response. The sensitivity of the triage tool in identifying patients with serious injury was 95.0%. Comparison of the review with a similar review performed 12 months earlier demonstrated that staff compliance with initiating the trauma team response had improved. Using data from 564 patients from both series, logistic regression analysis of the power of the triage criteria to predict serious injury contributed to a revision of the triage criteria. This trauma triage tool and trauma team response constitute a valid approach to the early hospital management of trauma patients. This system may be more appropriate or achievable in many hospitals than the construction of dedicated trauma reception units or permanent surgical staffing of general Accident and Emergency departments.     

A prehospital glasgow coma scale score < or = 14 accurately predicts the need for full trauma team activation and patient hospitalization after motor vehicle collisions

BACKGROUND: Trauma team activation protocols should ideally minimize the undertriage of seriously injured patients and eliminate unnecessary activations for those patients that do not require hospitalization. This study examined which physiologic parameter(s) most reliably predicted the need for hospitalization after motor vehicle collisions (MVCs). METHODS: A prehospital triage tool using standard physiologic parameters was developed and prospectively analyzed for reliability in predicting subsequent patient admission at a Level II trauma center after MVCs. Data were collected on 4,014 consecutive patients, 2,880 (72%) of whom had all of the physiologic parameters reported and recorded. Patients who arrived in extremis, who were dead on arrival, or who died shortly after arrival despite appropriate trauma team activation were ineligible for the study. Multivariate stepwise logistic regression analysis was used to determine which parameters were associated with hospital admission. RESULTS: The Glasgow Coma Scale (GCS) score was the only prehospital physiologic parameter providing a clinically identifiable difference between those patients admitted (13 +/- 4) and those discharged to home (15 +/- 0.5) (mean + SD) (relative risk for hospitalization, 2.24; 95% confidence interval, 1.86-2.70 for GCS score < 14). CONCLUSION: The prehospital GCS score is a reliable physiologic parameter for predicting hospital admission after MVC. When obvious indicators (hypoxemia, multiple long bone fractures, focal neurologic deficits) for trauma team activation are lacking, the prehospital GCS score may be used to reduce overtriage and undertriage rates.     

Identification of thoracic injuries by emergency medical services providers among trauma patients

IntroductionSevere thoracic injuries are time sensitive and adequate triage to a facility with a high-level of trauma care is crucial. The emergency medical services (EMS) providers are required to identify patients with a severe thoracic injury to transport the patient to the right hospital. However, identifying these patients on-scene is difficult. The accuracy of prehospital assessment of potential thoracic injury by EMS providers of the ground ambulances is unknown. Therefore, the aim of this study is to evaluate the diagnostic accuracy of the assessment of the EMS provider in the identification of a thoracic injury and determine predictors of a severe thoracic injury.MethodsIn this multicentre cohort study, all trauma patients aged 16 and over, transported with a ground erence standard. Prehospital variables were analysed using logistic regression to explore prehospital ambulance to a trauma centre, were evaluated. The diagnostic value of EMS provider judgment was determined using the Abbreviated Injury Scale (AIS) of ≥ 1 in the thoracic region as ref predictors of a severe thoracic injury (AIS ≥ 3).ResultsIn total 2766 patients were included, of whom 465 (16.8%) sustained a thoracic injury and 210 (7.6%) a severe thoracic injury. The EMS providers’ judgment had a sensitivity of 54.8% and a specificity of 92.6% for the identification of a thoracic injury. Significant independent prehospital predictors were: age, oxygen saturation, Glasgow Coma Scale, fall > 2 m, and suspicion of inhalation trauma or a thoracic injury by the EMS provider.ConclusionEMS providers could identify little over half of the patients with a thoracic injury. A supplementary triage protocol to identify patients with a thoracic injury could improve prehospital triage of these patients. In this supplementary protocol, age, vital signs, and mechanism criteria could be included.     

Avoiding Cribari gridlock 2: The standardized triage assessment tool outperforms the Cribari matrix method in 38 adult and pediatric trauma centers

ObjectivesThe Cribari Matrix Method (CMM) is the current standard to identify over/undertriage but requires manual trauma triage reviews to address its inadequacies. The Standardized Triage Assessment Tool (STAT) partially emulates triage review by combining CMM with the Need For Trauma Intervention, an indicator of major trauma. This study aimed to validate STAT in a multicenter sample.MethodsThirty-eight adult and pediatric US trauma centers submitted data for 97,282 encounters. Mixed models estimated the effects of overtriage and undertriage versus appropriate triage on the odds of complication, odds of discharge to a continuing care facility, and differences in length of stay for both CMM and STAT. Significance was assessed at p <0.005.ResultsOvertriage (53.49% vs. 30.79%) and undertriage (17.19% vs. 3.55%) rates were notably lower with STAT than with CMM. CMM and STAT had significant associations with all outcomes, with overtriages demonstrating lower injury burdens and undertriages showing higher injury burdens than appropriately triaged patients. STAT indicated significantly stronger associations with outcomes than CMM, except in odds of discharge to continuing care facility among patients who received a full trauma team activation where STAT and CMM were similar.ConclusionsThis multicenter study strongly indicates STAT safely and accurately flags fewer cases for triage reviews, thereby reducing the subjectivity introduced by manual triage determinations. This may enable better refinement of activation criteria and reduced workload.     

The diagnostic accuracy of prehospital triage tools in identifying patients with traumatic brain injury: A systematic review

IntroductionPrehospital care providers are usually the first responders for patients with traumatic brain injury (TBI). Early identification of patients with TBI enables them to receive trauma centre care, which improves outcomes. Two recent systematic reviews concluded that prehospital triage tools for undifferentiated major trauma have low accuracy. However, neither review focused specifically on patients with suspected TBI. Therefore, we aimed to systematically review the existing evidence on the diagnostic performance of prehospital triage tools for patients with suspected TBI.MethodsA comprehensive search of the current literature was conducted using Medline, EMBASE, CINAHL Plus and the Cochrane library (inception to 1st June 2021). We also searched Google Scholar, OpenGrey, pre-prints (MedRxiv) and dissertation databases. We included all studies published in English language evaluating the accuracy of prehospital triage tools for TBI. We assessed methodological quality and risk of bias using a modified Quality Assessment of Diagnostic Studies (QUADAS-2) tool. Two reviewers independently performed searches, screened titles and abstracts and undertook methodological quality assessments. Due to the heterogeneity in the population of interest and prehospital triage tools used, a narrative synthesis was undertaken.ResultsThe initial search identified 1787 articles, of which 8 unique eligible studies met the inclusion criteria (5 retrospective, 2 prospective, 1 mixed). Overall, sensitivity of triage tools studied ranged from 19.8% to 87.9% for TBI identification. Specificity ranged from 41.4% to 94.4%. Two decision tools have been validated more than once: HITS-NS (2 studies, sensitivity 28.3–32.6%, specificity 89.1–94.4%) and the Field Triage Decision Scheme (4 studies, sensitivity 19.8–64.5%, specificity 77.4%-93.1%). Existing tools appear to systematically under-triage older patients.ConclusionFurther efforts are needed to improve and optimise prehospital triage tools. Consideration of additional predictors (e.g., biomarkers, clinical decision aids and paramedic judgement) may be required to improve diagnostic accuracy.     

Should we still use motor vehicle intrusion as a sole triage criterion for the use of trauma center resources?

BackgroundMotor vehicle intrusion (MVI) is one of the field triage criteria recommended by the American College of Surgeons Committee of Trauma (ACS-COT) and Centers for Disease Control and Prevention (CDC). However, the evidence supporting its validity is scarce. The purpose of this study was to evaluate the validity of this criterion and assess its impact on overtriage or undertriage.Patients and methodsThis was a retrospective study based on the Los Angeles County Trauma and Emergency Medicine Information System (TEMIS) Trauma database. Included in the analysis were patients with MVI as the sole criterion for trauma center triage. Physiological characteristics, severity of injury, and outcomes of the MVI patients were compared between different age groups. Further, a logistic regression model was used to identify factors significantly associated with the need for trauma center resources.ResultsDuring the period 2002–2012, a total of 10,554 trauma patients involved in motor vehicle crashes had documentation of MVI. A subgroup of 3998 patients (37.9%) did not meet any other criteria that require immediate transportation to a designated trauma center. Only 0.7% of these patients had hypotension and 0.1% had deterioration of the Glasgow Coma Scale on admission to the emergency room. Overall, 18.8% of patients required trauma center resources defined as intubation in the emergency room, certain surgical procedures, in-hospital death, or intensive care unit admission. Age ≥65 years, male gender, prehospital heart rate >100/min, and systolic blood pressure <110 mmHg were significantly associated with the need for trauma center resources.ConclusionsThe MVI itself did not appear to be a strong indicator for the use of trauma center resources and is associated with excessive overtriage. However, age >65 years, systolic blood pressure <110 mmHg, and heart rate >100/min were significant predictors for the need of trauma center resources. The MVI criterion should be refined for better utilization of trauma center resources.     

Prehospital triage of trauma patients using the Random Forest computer algorithm

Background

Overtriage not only wastes resources but also displaces the patient from their community and causes delay of treatment for the more seriously injured. This study aimed to validate the Random Forest computer model (RFM) as means of better triaging trauma patients to level 1 trauma centers.

Methods

Adult trauma patients with “medium activation” presenting via helicopter to a level 1 trauma center from May 2007 to May 2009 were included. The “medium activation” trauma patient is alert and hemodynamically stable on scene but has either subnormal vital signs or accumulation of risk factors that may indicate a potentially serious injury. Variables included in the RFM analysis were demographics, mechanism of injury, prehospital fluid, medications, vitals, and disposition. Statistical analysis was performed via the Random Forest algorithm to compare our institutional triage rate to rates determined by the RFM.

Results

A total of 1653 patients were included in this study, of which 496 were used in the testing set of the RFM. In our testing set, 33.8% of patients brought to our level 1 trauma center could have been managed at a level 3 trauma center, and 88% of patients who required a level 1 trauma center were identified correctly. In the testing set, there was an overtriage rate of 66%, whereas using the RFM, we decreased the overtriage rate to 42% (P < 0.001). There was an undertriage rate of 8.3%.The RFM predicted patient disposition with a sensitivity of 89%, specificity of 42%, negative predictive value of 92%, and positive predictive value of 34%.

Conclusions

Although prospective validation is required, it appears that computer modeling potentially could be used to guide triage decisions, allowing both more accurate triage and more efficient use of the trauma system.     

The differential survival of trauma patients

Advances in prehospital care and the development of regionalized trauma centers have reduced the mortality from major trauma. However, patients who have sustained severe brain injuries (Glasgow Coma Score less than or equal to 8) treated in such a setting still have a substantial mortality. In order to determine if mortality is a function of severe brain injury, 545 trauma patients with and without severe brain injury were prospectively studied. All patients were similarly treated by one medical center from the actual site of injury until discharge from the hospital. There were 104 patients who had sustained major blunt trauma with severe brain injury and 441 patients who had sustained major blunt trauma without severe brain injury. The mortality of the former group was 30.8%, whereas that of the latter group was 0.9% (p less than 0.0001).     

Prospective evaluation of a two-tiered trauma activation protocol in an Australian major trauma referral hospital

Objective

To evaluate a two-tiered trauma activation protocol in a major trauma referral hospital in Australia.

Methods

A prospective study performed over a 12-month period of all consecutive trauma activations in a major trauma referral hospital. The triage tool assigned patients into two tiers of trauma activation. The full trauma activation was initiated where physiological or anatomical criteria were present. These patients were assessed by a multispecialty trauma team. A consult trauma activation was initiated where only mechanism of injury criteria was present. These patients were assessed by the Emergency Department Registrar and Surgical Registrar. The primary endpoint was major trauma outcome defined as either injury severity score (ISS) greater than 15, requirement for High Dependency Unit or Intensive Care Unit (HDU/ICU) admission, need for urgent operative intervention, or in hospital mortality.

Results

Of 1144 trauma activations, 468 (41%) were full trauma and 676 (59%) were consult trauma activations. The full trauma activation group had a significantly higher proportion of the major trauma outcome (34% vs. 5%, p < 0.01) and all 18 patients (2%) who died were in the full trauma activation group. Sensitivity of the triage tool for the major trauma outcome was 83%, specificity was 68%, undertriage was 3% and overtriage was 27%.

Conclusions

The two-tiered trauma activation protocol is effective in identifying patients with major trauma from those with minor trauma. There were no deaths in undertriaged patients.     

Improving the field triage of major trauma victims

The Trauma Scores, CRAMS scales, and mechanisms of injury of 500 trauma patients were evaluated for their ability to identify a seriously injured patient. Serious injury was defined as one of the following: Injury Severity Score (ISS) greater than 15, or emergency-room Trauma Score less than or equal to 14, or injuries requiring greater than 3 days hospitalization, or death. With the addition of specific mechanisms of injury (auto vs. pedestrian accident at greater than 5 m.p.h., motor vehicle accident at greater than 40 m.p.h., motorcycle accident at greater than 20 m.p.h., or a major assault), the sensitivity of a field Trauma Score of less than 14 could be improved from 45% to 75%, with a reasonable specificity of 40%. With these same mechanisms, the sensitivity of a CRAMS scale of less than or equal to 8 increased from 66% to 93%, with a specificity of 30%. The addition of these mechanisms of injury to standard field triage scoring appears to improve the identification of seriously injured patients while retaining an acceptable level of overtriage.